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R2 Advice
THE VIEW: A Survival Guide for the R2 (edition 2.6) By Formosa Chen updated 6/11/11 by Adam Oskowitz updated 6/28/12 by Justin Wagner/Denise Tai updated 6/29/14 by Josh Rouch updated 7/28/2014 by Tara Russell updated 6/21/15 by Mike Robinson updated 8/8/15 by James Wu Be A Good Doctor You may be the only MD who takes the history, exams the patient, reviews the labs and imaging (clinic, ED, etc). You will decide if they have undergone the appropriate work-up, have the right diagnosis and receive the right treatment. You are your patients’ doctor. Do a good job. You can make a big difference in the quality of care that patients receive. Strive to ensure that difference is always for the better. Never forget this. R2 Call '''Pager NP Call Pager Any OVMC Extension 818-313-0776 818-313-1551 818-364-xxxx Nursing '''Supervisor Office: 2C-210 (to drop pinks when nobody’s in the OR) IN GENERAL § There’s a lot of dressing up (Mon, Tues, Thur, and some weekends, depending on the rounding attending1). Either always dress up or have clothes in the call room at all times. § Where to find films: Synapse. For after-hour reads, ask the ED for the number of the night radiologist. You can also go find them in the reading room in the ED at night. § Scrubs: $20 refundable deposit per pair. Pay the Cashier on the 2nd floor (next to lobby). Scrub exchange machine in OR. You can '''only wear OV scrubs here. Bennion will crucify you if you show up with the wrong scrubs. § Meals: $6 for breakfast/$8 for lunch/$7 dinner per meal. Max is ~$60 a week. You can sign for it on the 1st few days until you get into the “computer.” Go to Dietary (1C112) to get inputted. Cafeteria is on the 1st floor. Closes at 19:30 § Wed morning conference at UCLA: swing R2 attends conference while the post-call and on-call R2 round with the post-call R3. The post-call R2 can operate until 10am. § UCLA pagers fail 50% of the time. If you have paged someone 2-3 times without response, call the operator, and overhead page them. Same goes for you: listen for overhead pages. Or sign your UCLA pager out to the call pager. Note the overhead paging system does not work in the OR. § There are LOTS of forms – when writing orders your first few weeks, feel free to ask if there is a specific form (for example there are separate forms for: any imaging other than portable CXR, contrast for CT scans, PCAs, any insulin orders, blood transfusion, restricted abx, echos, etc) ON CALL DAYS § Arrive at 06:00 § Pick up a list in the call room (4A129) § Post-call R2 examine all patients AFTER MIDNIGHT but prior to rounds at 6:00 Ø Take down all dressings on POD 2. Usually, BKA stumps taken down POD1 (take picture of wound). Ø Examine all wounds and drain output, and perform an ultra-focused exam; try not to get into any conversations with patients, there’s just no time. Come back later in the day to engage with patients. Ø Find out if they (1) have bowel sounds (2) passed gas (3) had a BM. (On rounds, you present it as “plus, plus, plus” or “plus, plus, minus” depending on what information you obtain.) § For patients awaiting return of bowel function, nausea/hunger, bloating/burping/hiccupping can sometimes sway diet decisions. Take the time to ask. Ø If you have time to examine routine lap chole or open appy pts, and notice that one of their dressings is soaked, it saves you time later if you just change it right then, or else you have to go back and change it before they go home that day. § 06:00 Rounds Ø Present all patients as follows…(or how your R3/R5 wants it) o Mr. So and so. Hospital day X, or Post-op day Y. o Diet: NPO, mIVF o Antibiotics: o PPX, Pain o Vitals o Ins and Outs, followed by breakdown o Plus, Plus, Plus o Labs, Cxs Ø The post-call and swing R2 will write the orders and help set up discharge work that was not completed the night before Ø Have a running list of all things that need to be done ON-CALL DAYS: CONSULTS § Consults: '''see the patient, (consent them), drop orders, add them to the list, write a note, make a card. Run '''ALL consults by on-call R3 (whether you admit or discharge). Ø Keep a card that lists/has stickers of all consults and give it to the attending on call the following day. Ø Look at all imaging yourself Ø Trust no one Ø At first if you think the consult is un-warranted check with the R3, otherwise see them all. Try to see them quickly, and not let them build up. You can get over 10 in one day. Ø Use the General Surgical H&P form on Clinical Work Station (or Vascular/Peds Surgery depending on the consult). Ø For your convenience, there are some old H&Ps saved in the “Templates” folder on the desktop. A couple of edits is a lot easier than having to synthesize a new H&P every time. Ø Consent all chole & appy pts when you see them in the ED if you know the attending of the day for the case Ø If a study needs to be done, have it done in the ED before the pt is admitted to the floor Ø If you already know what the consult is going to be (i.e., chole/appy), it makes it faster if you fill out all your forms (H&P, labs, consents) before you go down to the ED. Ø Make a card of all new pts for the R3. Card should have H&P, vitals, labs, imaging § Biliary Disease and its various manifestations Ø We do NOT admit symptomatic cholelithiasis unless they have intractable pain or nausea/vomiting (but always see the patient first, check with the R3 before you make the “PO challenge and follow-up in G-surg clinic” recommendation) Ø We need from the ED: labs (chem, LFTs, CBC, coags, etc) and ultrasound (document on the H&P GB wall thickness, CBD diameter, +/- pericholecystic fluid, etc.) Coags and urine pregnancy test are mandatory if we plan to operate. Ø Anyone middle-aged and older who you anticipate will get an operation needs a 12-lead EKG and a chest X-ray (ask the ED to do it if you can) Ø Orders: § Admit to 4A (or higher level of care if they are sick) § NPO, IVF, (NGT if they have intractable vomiting; Foley if cholangitis/GS panc and are “sick”) § Antibiotics:' Cefoxitin 1gm IV Q8hr or Ceftriaxone 1g q24hr' o None for symptomatic chole, GS pancreatitis o Yes for acute chole, cholangitis, o Check with R3 for choledocho with no signs of infection § Morphine 2mg IV q2 hours on the floor § Something for nausea (zofran)/ sleep (Benadryl/Restoril)/ fever/ headache (Tylenol) § Consider something PRN for Hx of HTN (hydralazine), § If PT>14.5: Vit K 10mg SC qday x 3 days § AML: CBC, Chem 10, LFT (amylase & lipase if GS panc).. Make sure female pts have pregnancy tests in system Ø CONSENT: On iMedConsent, set up your username and password or chole consents, use the “gallbladder - lap/open with possible CBD exploration,” also select possible “'Bile ducts - intraoperative cholangiogram',” and possible “Abdomen – exploratory laparotomy with possible interventions.” Ø On the list, please place “'GB#”' next to patients who are here for chole. This helps with organizing the patients for OR scheduling § Appendicitis Ø We need from ED: labs, +/- CT scan Ø To CT or not to CT: often, the ED has already gotten one. If the H&P are “classic” and the R3 agrees, we may operate without a scan. If the R3 wants a scan, do NOT admit the pt until the scan has been done. Ø Recent study re: non-operative management of appendicitis and randomizing patients into surgical/non-surgical control arms. If any questions, ask the ED resident if the patient “has been seen by the study coordinators.” Since advent of the study, we have always gotten CTs for r/o appys (inclusion criteria à lack of a fecalith) Ø Orders: NPO, IVF, Abx – cefoxitin 1gm IV Q8H Ø CONSENT': '''Appendix -' open appendectomy, possible laparoscopic appendectomy, possible bowel resection, possible exploratory laparotomy '''Dropping add-on cases Ø You must page the anesthesiologist on-call (AOD) for all pink slips prior to dropping them. Make sure to know the patients history, the MRN, location and last meal. This will save time. Ø Drop a “pink”: this is the OV “add on” form. You can find them in the OR & other various places.2 § During work hours, just take it to the OR (3rd floor) and give it to the OR charge nurse § After hours, take it to Nursing Administration (2C210), AND call anesthesia on call to get them to call in the team. Ø Operate that night if the pt can be in the room before midnight, but check with the R3 first always Ø Do NOT drop a pink unless the attending on call has been informed. ' ' Labs Ø Check them around 10:00-11:00 to be ready for running the list in early PM Ø Replace electrolytes, f/u cultures Ø Write all a.m. labs for midnight Consent ''' All consents are done on iMed-consent now you can create a log-in. Please have the consent printed in the '''patients native language and be sure to note the side for all procedures that are unilateral ' (this is not' needed for single internal organs: i.e. left sided gallbladder) ' ' § Orders: ''' There are “Surgery Admit” order forms at all nurse’s stations. Use these, as it can literally be filled out in less than 2 minutes and has everything you need. § '''Do not make copies of pre-filled orders. This is illegal and does not save you time. § All women going to the OR need bHCGs unless over 60 (a silly rule but not worth arguing) § All biliary cases should have a set of coags. If the coags demonstrate a PT greater than 14.5 write for vitamin K 10 mg SQ daily x 3 doses (another silly rule) § All patients over 40 need an EKG ' ' The List ' It will help you tremendously to keep it up to date § Remember to update room numbers early in the morning, patients move frequently § Copy and paste cells that autopopulate with the postoperative days and hospital days so you don’t have to manually change them daily § When a patient is discharged, cut and paste their row into the “Discharged” tab; this will save time if they bounce back § The quality of the list is a reflection of your attention to detail and how well you know your patients ' ' P'ost-op checks Like all other floor work, this is also your job. Students are very helpful in this regard, but do not replace EVERY post-op patient being examined by an MD. § Patients will try to bleed to death on you. Take your job seriously and do it well. § Cards to make each day: new/elective patients s/p OR, new consults (1 card for consult, 1 card with all consults and MRUNs for attendings) Daily Progress notes Ø You get the vitals & I&Os in the morning before rounds § For floor patients the vitals and I/O’s are in Clinical Workstation § Make estimates if the exact IV fluids or UOP are not yet charted or ask the nurse3 § For all ICU or step down patient the vitals, I/Os are located on a paper flowsheet at the bedside with the nurse. § All patients should have labs written down prior to rounds if you wrote a.m. labs to be drawn at midnight § The medical students (if available) will obtain all floor numbers, but you should review them. § All ICU/Step down numbers should be obtained by you only (because you not only write them down, you ponder them) Ø All patients with Central lines, including PICC lines, A-lines, CVC, Dialysis Catheters, Swans etc. must have a progress note that includes the central line and the indication '' '' CURRENT WAY TO DO NOTES Ø Please be very careful with CUT & PASTE. Do not perpetuate wrong information. Do not look stupid by copying notes that make no sense. Be careful “borrowing” from medicine notes. Always read what you write before you sign it. Make sure all information is still applicable. Ø Daily progress notes are typed in clinical workstation after rounds by the post call R2. Format all notes in the “Olive View IM Note” formatter online Ø To save you time, and pain, there is a word document called “NOTES” that is saved on the desktop for all current in-patients. Update the notes in this document and then paste them into CW. Keep this document update to make updating and entering notes as quick as possible for the person following you. Ø If you use the copy forward function within CW you need to follow the following instructions (which will save a lot of time): In the top left of the CW screen where you would normally select “Dictated Reports,” choose “NTM All Clinical Data.” Open yesterday’s note here and click “Copy Forward.” Edit away. If you do this, it useful to use the Olive View Internal Medicine Note Format tool '''(just search for it on google and you will find it). Helps to auto-format stuff that you copy/paste so that your note looks somewhat clean) § '''Discharge paperwork: For all patients for whom discharge is anticipated tomorrow, finish everything that needs to be done, so that the only thing that happens on rounds is writing the order “D/C IV, D/C home.” You cannot verbal d/c orders. Ø Discharge summary: There is a standardized form on the computer to follow § For routine lap chole & non-perf appy pts, they follow up with the Gen Surg NP clinic in 2-3 weeks § For your convenience, there is a template (prior saved discharge summary) for almost everything located in the “Templates” folder on the desktop. Help the future and save a new file for anything major that you change on them. Ø Prescriptions: Use a regular script if you are not giving narcotics. Include a CA license/DEA number on the script so the pharmacy doesn’t call you about it later. Be sure to have enough narcotics scripts from seniors before they leave. Ø Dictation. You need your provider number for these.4 Until you get it, here’s what you do: dial “#6788”, for provider code, enter “your dictation code” and follow instructions thereafter. § The on-call person dictates the people he/she discharges. You just get the paperwork ready. Ø Weekend discharges: § Keep a list of all patients discharged over the weekend § Give the list to Debbie on Monday § She will make sure the ALL have appropriate clinic follow-up § If we do not do this, >10% of our patients will not get appropriate post-op outpatient follow-up. Bad doctor. POST-CALL DAYS § By 06:00 rounds you should have… Ø Updated and printed the list (by 5am) Ø Printed the I&Os sheet for the med students (by 5am) Ø T’d patients up for discharge (Discharge form filled out, all scripts written, reconciled all home meds) Ø Written any orders for imaging or more complex orders that can be anticipated for rounds Ø Have any pink slips ready to drop in the OR Ø Made a card for each of the new pt’s to give the R3 Ø Made a card with all Consults with just names and MRNs for all new pts to give to the attending to sign § Helping on rounds… Ø Write orders Ø Rule of thumb for routine AM labs for the next day: § Write for all AM Labs for MIDNIGHT § NPO pts: Chem 10 § Infected pts: CBC § Pre-op chole: Chem 10, CBC, LFT (amylase/lipase if pancreatitis) on HD 1 only § No post-op AML for lap chole or open appy § No CBC for open appy (perf’d) until POD 4 or 5, or if the R3 specifically asks for it § On Wednesdays you can operate Post-call!! But check yourself – are you rested enough? Is it safe? Bennion’s rule is that you have to stop operating at 10am. This is a great opportunity and you often get to do upper level cases. We CANNOT go over hours to stay and operate – so watch your hours, be responsible, get out of the hospital as soon as your done operating. SWING DAYS § On Mondays, show up at noon for General Surgery Clinic (the Peds Surg Clinic will now be covered by the on-call R2 and medical students). Tuesday, Thursday, and Friday show up at 06:00. Wednesday go to UCLA conference and come to OVMC right afterwards to operate. If you’re swing on Saturday or Sunday, that’s your day off. § Help on rounds. Write orders. § Go to clinic: § Monday p.m. is General Surgery clinic § Tuesday a.m. alternates weekly between Vascular and Procto clinic § Tuesday p.m. is Breast clinic § Thursday a.m. is General Surgery clinic § Thursday p.m. is Thoracic clinic (not too many pt’s but each one takes forever), every other week § Operate on Weds & Fridays § Help the on-call person § Preop: After clinic on Tuesdays and Thursdays investigate which cases are scheduled for tomorrow and type up H&Ps to e-mail to the team for every elective surgery. You’ll also type and print the iMed Consents for them all and attach them to the charts to have ready for the morning. This process is tedious and your consents must be perfect or else the case may be delayed and the on-call R2 will have to stretch to clean up the mess. § If there are any questions about what needs to be included on the consent, ASK the ATTENDING § Monday and Thursday afternoon after preop, go to Medical Records (1st floor) office to rectify any and all deficiencies left over in old charts. Mostly, these amount to unsigned verbal orders (just need a signature, time, and date), but can also include discharge summaries, inconsistencies in H&Ps or operative reports, and commonly absent brief op notes. OPERATING § Do not be in the room any later than your patient § Ensure the H&P for your case is signed in CW and print out a copy § Type and sign the “Preop H&P Update” (The OV “SCIP”) in CW § Consent your patient and make sure it’s in the right language (check the administrative data tab in CW) § Grab a set of blank orders and have them ready to fill out for when the case is over. For appendectomies and lap choles there are pre-printed pathway order sets available in the PACU immediately to the right of the main entrance § Operate on your patient, make mental notes of what you’ve done § When you’re finished, immediately type your brief op note, this will save everyone a lot of stress § Dictate your operative report for any case where you’re first assistant § If you anticipate your patient will be discharged in the next day, get your discharge papers filled out and don’t forget a narcotic prescription § Log your case on the ACGME website § Sign out to the on-call R2 if it’s not you what you did and if the patient is going to be admitted NURSE PRACTITIONER § Debbie will make your life much easier. She is here M-F 6am-3pm. (every other Friday off) § Roles she has been playing: Dispo planner (ie, facilitating SW, Home Health, obtaining VAC), helps with discharges and DC summaries, covers R2 pager if you are in the OR. WILL DIVERT MOST OF THE FLOOR PAGES!! (Lovely not to be paged every 10 minutes by every floor). § Please make sure that all patients who will be discharged home that are on 4A and 4D have the MD order in the chart no later than 10am § For all weekend discharges please keep a list of who went home and hand the list to the NP on Monday so that a follow up appointment can be scheduled, if there is not already one scheduled = Frequently Used CPT Codes for logging cases ' ' APPENDECTOMY § 44950 – open § 44960 – perforated § 44970 – laparoscopic HERNIA REPAIR § 49560 - reducible "ventral" - VHR § 49561 - incarcerated "ventral" - UHR § 49585 - umbilical" - UHR (49580 if <5) § 49507 - "inguinal" - IHR - (incarcerated) § 49520 - "inguinal" - IHR - (recurrent) § 49505 - initial § 49500 - (6mo-5yrs) § 49495 - (>6mos) § 49659+49568 laparoscopic VIHR § +49561- initial / 49566 - recurrent VASCULAR § 36821 - most primary fistulas § 36830 - synthetic graft forearm AV fistula § 36819 - basilic vein transposition § 36820 - forearm vein transposition § 35206 - repair artery for trauma – arm § 37618 - ligation artery for trauma - ext. § 27590 – AKA § 27880 – BKA § 35301 – CEA § 37720 - GSV stripping § 37785 - varicose vein excisions ' ' BREAST § 19120 – Breast excisional biopsy § 19125 – wire localized breast biopsy § 38525 – Breast SLN biopsy § 38745 – Axillary lymph node dissection (ALND) § 19302 – partial mastectomy with ALND § 19303 – simple mastectomy § 19307 – modified radical mastectomy (MRM) GI § 49320 - dx-laparoscopy § 49000 - ex-lap § 43840 - Graham patch – gastric § 44602 - Graham patch - duodenal § 43501 - repair bleeding ulcer § 13160 - secondary abdominal closure § 44139 - mobilzation of splenic flexure § 44625/26 - colostomy takedown § 44015 - feeding jejunostomy § 44120 – small bowel resection § 44005 – enterolysis § 46080 – sphincterotomy § 46270 – fistulotomy § 46945 - ligation of hemorrhoids CHOLECYSTECTOMY § 47600 - open chole § 47562 - lap chole I&D § 11005 - major debridement (e.g. necrotizing fasciitis) § 46050-perianal/buttock § 46040 - ischial or perirectal § 10061 – I+D complex TRAUMA/ICU § 31600 – trach § 32020 - chest tube § 36556 - central line § 93503 - Swan-Ganz § 36620 - 36620 A- line (perc) § 49000 - ex-lap § 38100 – splenectomy § 44110 – repair bowel enterotomy § 44602 – repair small intestine for perforation § 44603 – repair small intestine for perforation (multiple) § 44604 – repair colon perforation (without colostomy) § 44605 – repair colon perforation (with colostomy) § 44850 - mesenteric repair § 20100 - neck exploration § 49002 - reopening of recent laparotomy § 13160 - secondary closure of surgical wound ' ' Olive View DICTATION 877-573-3205 or x6877 Get your Dictation ID# from Judy WORKTYPE D/c summary (1); Op Report (2) Progress Note (3); H&P (4) --> STAT (10) FUNCTIONAL BUTTONS Pause (1); Dictate (2); Rew 5 secs (3); Fast Fwd to End (4) Fwd 5 secs (6); Rew to Start (7); Next Report (8); STAT (*); Disconnect (#) ' ' OP NOTE REQUIREMENTS Dictator name Patient name Patient MRN Date Attending Resident/assistant Pre-op Dx Post-op Dx Procedures performed Anesthesia H&P/Indication Findings Description of procedure(s) EBL Implants/Drains Specimens Complications 1 If Drs. Gibbons or Bennion are on-call on weekends, you have to dress up. 2 Your R3 will tell you when to drop the pink. 3 Or you can harass the nurses for the exact I&O’s if it’s a patient for which the numbers is “problematic” (e.g., pt with low UOP, and you’re not sure if it’s because it’s not well documented, or if they failed to call you during the night, etc.) 4 Get your codes for dictating/ AffinityClinical work station access from the general surgery office (just call, they can tell you over the phone).